No Surprises Act Information & Disclosure

• No Surprises Act Information & Disclosure

  YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS (OMB Control Number: 0938-1401)

  When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

  What is “balance billing” (sometimes called “surprise billing”)?

  When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,     such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

  “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

  “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

  You Are Protected From Balance Billing For:

  Emergency services: If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

  Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections  not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance  bill you unless you give written consent and give up your protections.

  You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

  When balance billing isn’t allowed, you also have the following protections:

  You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

  Your health plan generally must:

   o   Cover emergency services without requiring you to get approval for services in advance (prior authorization).

   o   Cover emergency services by out-of-network providers.

   o   Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

   o   Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

   If you believe you’ve been wrongly billed, you may contact: The Oregon Board of Licensed Professional Counselors and Therapists: (503) 378-5499 or lpct.board@mhra.oregon.gov

  Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.

  Visit https://www.oregon.gov/oblpct/pages/index.aspx for more information about your rights under the state of Oregon.

  Note:

  This document was originally written by the Centers for Medicaid and Medicare (December 2021) and posted on their website. The No Surprises Law has already seen several revisions, so it is subject to change. Centers for Medicare & Medicaid Services. (2021). Standard Notice and Consent Documents Under the No Surprises Act (For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022). https://www.cms.gov/files/document/standard-notice-consent-forms-nonparticipating-providers-emergency-facilities-regarding-consumer.pdf

It’s Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:
•      Get a copy of your paper or electronic medical record
•      Correct your paper or electronic medical record
•      Request confidential communication
•      Ask us to limit the information we share
•      Get a list of those with whom we’ve shared your information
•      Get a copy of this privacy notice
•      Choose someone to act for you
•      File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:
•      Tell family and friends about your condition
•      Provide disaster relief
•      Include you in a hospital directory
•      Provide mental health care
•      Market our services and sell your information
•      Raise funds

Our Uses And Disclosures

We May Use And Share Your Information As We:
•      Treat You
•      Run Our Organization
•      Bill For Your Services
•      Help With Public Health And Safety Issues
•      Do Research
•      Comply With The Law
•      Respond To Organ And Tissue Donation Requests
•      Work With A Medical Examiner Or Funeral Director
•      Address Workers’ Compensation, Law Enforcement, And Other Government Requests
•      Respond To Lawsuits And Legal Actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record•      You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
•      We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record•      You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
•      We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications•      You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
•      We will say “yes” to all reasonable requests.

Ask us to limit what we use or share•      You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
•      If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information•      You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
•      We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you•      If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
•      We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated•      You can complain if you feel we have violated your rights by contacting us using the information on page 1.
•      You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.•      We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
•      Share information with your family, close friends, or others involved in your care
•      Share information in a disaster relief situation
•      Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:
•      Marketing purposes
•      Sale of your information
•      Most sharing of psychotherapy notes

In the case of fundraising:
•      We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses And Disclosures

How Do We Typically Use Or Share Your Health Information?

We typically use or share your health information in the following ways.

Treat youWe can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition. 

Run our organizationWe can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.  

Bill for your servicesWe can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.  

How Else Can We Use Or Share Your Health Information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issuesWe can share health information about you for certain situations such as:
•      Preventing disease
•      Helping with product recalls
•      Reporting adverse reactions to medications
•      Reporting suspected abuse, neglect, or domestic violence
•      Preventing or reducing a serious threat to anyone’s health or safety

Do researchWe can use or share your information for health research.

Comply with the lawWe will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requestsWe can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral directorWe can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information about you:
•      For workers’ compensation claims
•      For law enforcement purposes or with a law enforcement official
•      With health oversight agencies for activities authorized by law
•      For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actionsWe can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

•       We are required by law to maintain the privacy and security of your protected health information.
•       We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
•       We must follow the duties and privacy practices described in this notice and give you a copy of it.
•      We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes To The Terms Of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of date of distribution (per EHR record), as provided by:
Camaraderie Counseling LLC
Jeannie Balenger, Professional Counselor Associate
jeannie@camaraderie-counseling.com
971-258-2716